Psychache

In over fifty years of research and clinical practice with suicidal individuals, Shneidman’s main goal was to consider what was common across every suicide. Relatively early in his career, in his book Definition of Suicide (1977), he deliberately ignored psychiatric categories and demographic statistics, he assumed that all suicidal individuals are perturbed (agitated or upset), and he sought to identify the elements common to every suicide in the Western world. He was primarily interested in understanding the suicidal state from the INSIDE– what suicide is like and what is sensible about it to the person who is suicidal. This led him draft the Ten Commonalities of Suicide, and he further organized these commonalities in terms of six aspects of the suicidal state.

As he considered these ten commonalities, he realized that as reflecting a view influenced by theory of the human personality (Henry Murray), systems theory, and a common-sense cosmological scheme.

He said this: “I aim for a practical definition, guided by wisdom and common sense, that applies sensibly to almost every conceivable situation of self-destruction, whether done characterologically by a Cesare Pavese; thoughtfully and on principle, by a Socrates; dyadically by a John Doe with cancer who arranges his own death; or reflexively, born out of the moment and the esprit de corps by a soldier in combat who throws himself, in the presence of his comrades, on an enemy grenade. Each of these instances, I would maintain, can be meaningfully conceptualized, and in some cases could have been usefully treated, in terms of the ten commonalities of suicide” (Shneidman, 1977, 122).

Shneidman then considered the theory of Henry Murray, that every human personality is motivated by a unique constellation of psychological needs. Shneidman used twenty of these needs to create a check list of personality needs so that he could rate his clients to indicate how the various needs influenced their view of themselves and the world. The idea is to rate the needs (for oneself or for another individual) so that the numbers add up to exactly 100. The needs are rated according to how important a particular need seems to be to that person– the more important the need, the higher the number. The differences in how the needs are weighted provide a portrait of an individual personality.

Look at the form and think about your own personality. Rank order the needs you have, give the needs that are important to you high numbers; give those that are not important to you low numbers or even zeros. The sum of all the numbers should be 100. The constellation of needs you have checked will offer you a snapshot of your personality.

To offer an example of how this works, consider an individual (we’ll call her Suzy) who likes a lot of control in her life, who must make firm plans for her future, is very rigid and inflexible, have every item in place, and minimize all guess work to her life. This person might have high numbers beside Order. If one of the reasons Suzy must be in control is to remain safe and avoid risk, she might also score high in Harmavoidance, Inviolacy or Shame-avoidance. But in this case, Suzy’s motivation has more to do with success in her career, and she scores high in Achievement. In addition, Suzy never married, lives alone, and is not close with family members (her siblings live quite some distance away and the family was never close). In addition to striving for professional success, Suzy also volunteers her time to help families complete their tax returns every year, and she enjoys going to museums, dining out with friends, and reading history books.

Shneidman theorized that there are, for each individual, two sets of needs. One is the modal needs, the ones that the individual lives with on a daily basis. The other set is the vital needs– the ones on which an individual focuses when under extreme stress. These are the needs the individual is willing to die for. It is the pain created by thwarted vital needs that Shneidman called psychache– intolerable psychological pain.

In thinking about the suicidal state, Shneidman further considered what conditions are necessary for an individual to become actively suicidal. When stress (what Shneidman called “press”), perturbation (agitation) and psychological pain are all at maximal levels, a perfect storm of psychache and suicidality can be created in the mind of an individual. It is at this point that an individual’s lifelong coping patterns, presence or absence of perceived support mechanisms, and reasons for living/dying come into play, influencing the direction an individual may take, spiraling into a suicidal state or countering a suicidal state as protective factors.

Shneidman also suggested that most suicides can be categorized under one of the following five clusters of psychological needs, which reflect five different kinds of psychological pain. Of course, these five clusters are not exhaustive; every suicide should be understood according to its own unique details and context.

Let’s think about Suzy again. Her high scores in Achievement and Order indicate that she is a person who likes to have control over most aspects of her life. She likes to be able to predict what is going to happen in her foreseeable future. If Suzy is suddenly laid off by her employer and the career she spent the last twenty years developing is suddenly over, she will be faced with the possibility of fractured control in her life. Losing her job represents the stress/press in her life. She may also have other stresses that contribute to her press level, such as bills she needs to pay while faced with a drop in her income. Her level of psychache– because of thwarted needs for Order and Achievement– is at an all-time high. Whether or not Suzy becomes actively suicidal will depend on a variety of factors: her threshold for pain, her lifelong coping patterns, various protective factors in her life (such as religious beliefs, friends, or other elements that might be called reasons for living), whether or not her psychological pain and stress are accompanied by increasing agitation or perturbation, and whether or not she has access to means.

Her psychache could overwhelm her, the perturbation level could rise, and some of the other elements of a suicidal state (such as constriction) could severely restrict her ability to see other options. If the storm becomes too dark and too painful, Suzy may feel unable to face another day tolerating this level of pain. She may seek other ways of making the pain stop. She might try self-medicating with drugs or alcohol, but she may find the results short-lived. Her level of agitation is rising. Her pain may reach intolerable levels. Her options become narrowed and she may reach the point where her choices seem to be two, and only two: Continue to live with this horrendous, screaming ache in her mind; or kill her body and stop the pain.

David Jobes has said that most suicidal people do not want to end their biological existence. They want to end their suffering (Jobes, 2006). Shneidman would agree: “To understand suicide we must understand suffering and psychological pain and various thresholds for enduring it; to treat suicidal people (and prevent suicide) we must address and then soften and reduce the psychache that drives it. Everyone who commits suicide feels driven to it – indeed, feels that suicide is the only option left” (Shneidman, 1996, 13).

Comments

02/05/2015 at 6:48 PMchris
I agree, very accurate and interesting read. I'm thinking direct knowledge like this could help out people with psyche pain tremendously, though in the end it comes down to working out the individual's issue.

09/05/2013 at 9:40 AMrex zark
Yes, this article provides a perfect suicide note. Never underestimate how suddenly things may change, when you think life is starting to be bearable again. A straw does indeed break a camel's back.